Other Public Health Resources
Information Regarding the October 1 change for Schedule II Prescription Paper
Online Analytical Statistical Information System
Georgia Department of Public Health Programs
Georgia Department of Public Health Publications
Georgia Department of Public Health Resources Index
District Director Contact Information
2011 Women's Right to Know Reporting Form
Women's Right to Know Provider Letter
Atlanta STI Resource for Underserved: SisterLove, Inc.
SisterLove, Inc. (SLI) in partnership with the Georgia Department of Public Health is pleased to announce the launching of its new expanded STI Testing Program. A long sought after goal, SLI now provides testing services beyond HIV to communities of color at low or no cost. As part of the Georgia Infertility Prevention Project (IPP), Sister-Love now offers Chlamydia and Gonorrhea testing.
SisterLove's established presence and positive reputation in various communities eased the expansion of this initiative to include Chlamydia and Gonorrhea testing as an addition to rapid HIV testing and counseling program. Through this new expanded program, patients have the option of free testing as well as referrals to treatment sites if they test positive. SLI has three partner sites that will provide prescriptions for cost-effective treatment. The patient has the option to seek services at the clinic that is most convenient for her or him.
SisterLove has partnered with medical centers to increase access to treatment and care in Atlanta. Andrea Saboor, MSN, FNP-C, provides pro-bono treatment services at Absolute Care Medical Center in Midtown. In addition to receiving free treatment, the patient will also be screened for Syphilis free of charge. Hermeyone Wilson, APRN, provides space at the Edgewood Medical Center for SLI to offer free HIV/STI screenings. With this new IPP initiative, SisterLove is able to provide greater prevention and intervention services to underserved minority communities.
For additional information contact Michelle Allen, State STD Office Director - Georgia Department of Public Health, Office of Infectious Disease and Immunization Program mlallen2@dhr.state.ga.us
GAFP Members in Northeast Georgia: Now Hear This!!!
The New Hearing Screening Follow-up Clinic is busy working with families and physicians to increase follow-up infant hearing screenings in the Gainesville Health District.
The Georgia Universal Newborn Screening and Intervention (UNHSI) program is responsible for ensuring that every infant with hearing loss born in Georgia is diagnosed and linked to early intervention services by 6 months of age, in accordance with national Early Hearing Detection and Intervention (EHDI) goals. To meet this goal, infants who fail the initial hospital screen need access to follow-up screening services.
In 2010, the District 2 UNHSI program opened a new clinic dedicated to providing outpatient services for infants who require follow-up newborn hearing screens. The clinic opened in response to the Northeast Georgia Medical Center no longer offering outpatient follow-up newborn hearing screens. The new clinic provides timely follow-up screening services to infants who missed or received a "refer" result on their initial hearing screen. In addition to serving infants, clinic staff also provides education to families, physicians and other providers on the importance of screening, tracking, and follow-up for these babies. The clinic uses Automated Auditory Brainstem Response (AABR) equipment, which tests the entire hearing pathway from the ear to, and including, the brainstem.
The clinic has grown significantly, increasing operation from a one-half day session per month to a full day clinic twice per month. The average number of patients screened in the clinic has climbed from two to fourteen. The number of infants tracked for follow-up hearing screening increased from 72 percent in state fiscal year (SFY) 2010 to 93.4 percent in SFY 2011. The total number of infants tracked to audiological diagnostic evaluation also increased from 55.5 percent in SFY 2010 to 94.5 percent in SFY 2011. The staff believes the success of the clinic is a result of having more control over the scheduling of appointments, having more time to educate parents on the need for audiological intervention and giving providers follow-up information at the same time that they receive the results of the screening.
In April 2011, District 2 also received additional funds to purchase Automated Tympanometry Screening equipment to test babies that do not pass follow-up AABR or Automated Otoacoustic Emissions (AOAE) hearing screens. Screening tympanograms are used to evaluate middle ear functioning by measuring pressure within the middle ear. Tympanograms can assist in identifying if fluid in the middle ear is the cause for an infant not passing the initial and follow-up hearing screen. District 2 staff trained with an audiologist on the use of the equipment and began including tympanograms in all follow up screening procedures in August 2011. Future plans include hiring an audiologist and expanding services to include diagnostic ABR.
For further information about the Gainesville UNHSI Newborn Screening Follow-up Clinic contact Florence Freeman, RN, the Universal Newborn Hearing Coordinator at fmfreeman@dhr.state.ga.us or Tonya Newsom, LPC, MA, MBA, the Children 1st & Language Access Coordinator at tenewsom@dhr.state.ga.us.
Bioterrorism Preparedness and Family Physicians
Since the first anthrax attack, up to and including the recent H1N1 epidemic, there has been an increased awareness of the importance of public health and the medical community working together. A federal response resulted in the Public Health Security and Bioterrorism Preparedness and Response Act of 2002 and the Pandemic and All-Hazards Preparedness Act of 2006, which created new roles for emergency preparedness and response.
Family physicians and other primary care physicians have a vital role in protecting our patients and our nation against bioterrorism. An astute physician who diagnoses a reportable illness and alerts the local health department may be detecting a bioterrorism attack, possibly saving their patient and many others.
An important step is preparing your office. This includes creating a convenient and reliable system to report disease to your state and local health departments. Getting to know the public health professionals in your area will make communication easier in case of disaster, whether bioterrorism or otherwise. Use of electronic health records in conjunction with office web sites and social media can help communicate with patients and other health professionals about changes in office hours, self-treatment recommendations, and public health information.
Another step in bioterrorism preparedness is getting involved in community, state, and national initiatives. There are many ways to get involved. The Medical Reserve Corps uses volunteer health professionals to supplement local emergency and public health resources. The Emergency System for Advance Registration of Volunteer Health Professionals system keeps an up-to-date list of credentialed volunteers who can be deployed swiftly to assist with disaster relief. Here in Georgia you can register with SERVGA. This organization integrates government-sponsored local, regional and statewide volunteer programs to assist emergency response and public safety organizations during a disaster. It is part of a national initiative to coordinate and mobilize volunteers to respond to all types of emergencies. To learn more or to register for SERVGA, go online to www.servga.gov
Bioterrorism is a threat to all Americans. Family physicians, by preparing themselves, their families, their practices, and their communities, play a vital role in prevention and response. For a complete copy of the American Family Physician article, Bioterrorism and the Vital Role of Family Physicians visit: http://www.aafp.org/afp/2011/0701/p18.html
Childhood Obesity – A Valuable Resource for Family Physicians Now Available
The Division of Public Health has developed a valuable resource for clinicians who work with overweight patients. Now on the Public Health website is a list of available registered dieticians in the state, along with their contact information. To access this list, visit http://health.state.ga.us/nutritiondir/index.aspx
In a recent survey of GAFP members, it has been found that the majority of family physicians believe they are well prepared to counsel families about obesity and are comfortable doing so. When a child has been identified as being obese, with or without complications, the family physicians surveyed nearly always take the following actions:
- Monitor weight more frequently.
- Provide counseling on exercise, diet or nutrition.
- Refer to a dietician (outside their practice).
Unfortunately, there is often not enough time during a well visit to provide counseling to the child and their family. The physicians believe that a dietician's services would be helpful, but often do not have the resources to refer.
Preconception Care – A Tool for Family Physicians
Preconception Care – A Tool for Family Physicians Primary care physicians can significantly reduce the infant mortality rate in Georgia by providing specific health care measures to girls and women before they become pregnant. There are tools available for integrating preconception care into primary health care visits.
The Georgia Academy of Family Physicians, in collaboration with the Georgia Division of Public Health, has available a Preconception Toolkit developed by our very own, GAFP Member Dr. Anne Lang Dunlop. In 2010, every active GAFP member was mailed a copy of the toolkit to use in their office. The toolkit includes information on:
• Screening for reproductive intentions and risk of unintended pregnancy
• Assessing for medical, obstetrical, psychosocial, environmental, and genetic/familial risks
• Documenting proper CPT codes for reimbursement of preconception care services
The Preconception Care Toolkit also includes patient education brochures, in English and Spanish, which can be photocopied for distribution. Brochure topics include "Improving Your Health" and "Pregnancy Planning-Birth Spacing," and address specific conditions such as hypertension, diabetes, thyroid disorders, seizure disorders, lupus, depression, and smoking. Additionally, the toolkit contains physician resources that can be used to guide the reproductive health interview, answer common reproductive health questions, and provide E/M Codes applicable to provision of preconception care services.
New this year an additional brochure is being developed to address the importance of oral health and its relation to premature births.
This spring, GAFP members will receive an invitation to complete an online survey regarding your experience with the toolkit. Your feedback and input on the usefulness of this Preconception Care Toolkit will be very valuable for the Division of Public Health/Maternal Child Health staff as they plan future initiatives to reduce infant mortality in Georgia. For additional information contact Cathi Durham, GAFP Director of Outreach, at (800)392-3841 or by email at cdurham@gafp.org.
Family Physicians Integral in Early Detection of Hearing Loss
Georgia's Universal Newborn Hearing Screening and Intervention (UNHSI) program is an early hearing detection and intervention program aimed at preventing delays in language and social-emotional development. Family physicians make a substantial difference in the success of Georgia's UNHSI program by acting as a primary referral source and advocating on behalf of their patients for timely follow up services. Understanding the UNHSI program and advocating for hearing screening is the critical link in promoting positive social, emotional and educational outcomes for children at risk for hearing loss.
Georgia's UNHSI program begins with an initial hearing screening in the hospital. If the infant passes this screening, with no risk factors present, then the physician is notified that no further testing is necessary via the discharge paperwork. However, if the infant either does not pass the screening (also known as 'refers' or 'fails'), does not receive the screening, or passes with risk factors present, the physician is notified that further testing is necessary by the appropriate UNHSI District Coordinator. The UNHSI District Coordinators responsibility is to work in partnership with the parents and physician to obtain appropriate follow up testing and intervention services for the infant if necessary. To contact the UNHSI Coordinator in your area call 404-657-4143.
To meet the National Early Hearing Detection and Intervention (EHDI) goal of initial screening by one month of age, it is important to refer these infants for a follow up hearing screening within two weeks of receiving the referral. The follow up screening is performed to rule out the suspicion of hearing loss and to determine whether or not further diagnostic testing is necessary.
There are two types of hearing screening tests that can be performed on infants. Automated Otoacoustic Emissions (AOAE) testing involves placing a small probe at the entrance of the ear canal and measuring an 'echo' response from the inner ear. Automated Auditory Brainstem Response (AABR) testing involves placing electrodes several places on the infant and measuring brainwave response elicited by an auditory stimulus. Both tests are simple and nonintrusive to the infant.
The type of hearing screening test performed during follow up is determined by the type of hearing screening the infant received in the hospital. If an AOAE has been performed on the infant in the hospital, then follow up screening can be completed with either an AOAE or an AABR. If an AABR has been performed on the infant in the hospital, then follow up MUST be completed utilizing an AABR. An AABR is required because an AOAE does not diagnose a type of hearing loss known as Auditory Neuropathy. Thus, an infant may fail an AABR and pass an AOAE but still have profound permanent hearing loss. Therefore, to ensure that patients are receiving the most appropriate and comprehensive care, it is vital that physicians are aware of the type of hearing test that has been performed in the hospital and the type of hearing test being performed during follow up.
For questions on follow up hearing screening or diagnostic hearing testing, call Sarah Rank, AuD, State UNHSI program Coordinator, at (404) 657-4143. To make a referral to the Children 1st Program call 1-800-822-2539. You may also contact Cathi Durham, GAFP Director of Outreach at 800-392-3841 or cdurham@gafp.org.
Georgia Physicians Required to Report Abortions Performed
The Woman's Right to Know Act (WRTK) requires physicians performing abortions to submit an annual reporting form to the Department of Community Health (DCH). On December 1, 2010 DCH released a letter to physicians regarding reporting requirements under the WRTK Act. The letter is available on the GAFP website here.
The WRTK law requires that pregnant women seeking an abortion are offered the opportunity to view an ultrasound and hear the fetal heartbeat. Geographically-indexed information regarding the availability of free ultrasounds must also be made available. The physician who performs abortions is also required to report the number of patients who were provided the opportunity, the number of those who elected to view the sonogram, and the number who elected to hear the fetal heartbeat.
Under this law, physicians performing abortions must submit the WRTK Annual Reporting form, available at http://health.state.ga.us/wrtk/physicians.asp, on or before February 28 of every calendar year, or be subject to a late fee of $500 and possible reporting to the Composite Board of Medical Examiners. The referenced statutes may be accessed at: http://www.legis.state.ga.us. You may also access the Annual Reporting Form on the GAFP website here.
If you have questions about the reporting requirements, please contact the Maternal and Child Health Program, Perinatal/Women's Health Unit at 404-651-7691 or by email at wrtkinfo@dhr.state.ga.us
Family Physicians' Reimbursement for Fluoride Varnish Application
Family physicians are now being reimbursed for applying topical fluoride varnish to pediatric patients covered by PeachCare for Kids and all three Medicaid Care Management Organizations (CMOs). This benefit allows therapeutic application for recipients ages one month to 13 years, 11 months. The procedure is relatively simply and training can be obtained online at: http://www.smilesforlife2.org/default.aspx?tut=555&pagekey=62948&s1=1075854. The American Academy of Family Physicians endorses this oral health program. Other online training available at this site includes the oral health assessment which is required at a child's 6 month and 9 month visit, according to Medicaid's Health Check Manual.
The code to use when filing the claim is D1206. The service is billable under the following Categories of Service: 430 physicians, 431 physician assistants, 740 advanced registered nurse practitioners, or 450 dentists. The reimbursement is $17.50 per application.
The varnish does not require special storage, such as refrigeration. Varnish can be ordered online; a few of the available sites are:
Patterson Dental: http://www.pattersondental.com/ 800-328-5536
Sullivan-Schein: www.henryschein.com/ 800-372-4326
Medicom http://www.medicom.com/
Colgate Professional: http://www.colgateprofessional.com/
Medical Products Laboratories: http://www.medicalproductslaboratories.com/public-health/varnishamerica.html
Other oral health resources are available online from the Georgia Division of Public Health at: http://health.state.ga.us/pdfs/familyhealth/oral/ohprevention.pdf
For additional information, contact Cathi Durham at cdurham@gafp.org or 800-392-3841.
Public Health Programs Lunch and Learn, for you and your staff
GAFP would like to offer you and your office staff the opportunity to learn more about the Public Health Programs WIC and the new food package/formula guide, Children 1st, Babies Can't Wait, and Newborn Metabolic and Hearing Screening. A local public health coordinator for each program will provide information on services, eligibility, and the referral process.
All this and LUNCH, too!
To schedule please contact Cathi Durham, Director of Outreach at (800) 392-3841 or cdurham@gafp.org.
Free In Office Training for Your Staff
ASQ-3 is the most accurate, cost-effective, and parent-friendly way to identify children from one month to 5½ years with developmental delays.
It is:
- Recommended by the experts. The American Academy of Neurology and the Child Neurology Society recommend ASQ-3 as a high quality screener. ASQ-3 is also highly rated by the U.S. Department of Health and Human Services, Administration for Children and Families.
- Accurate. Rigorous research with more than 12,000 children shows that ASQ-3 is reliable and valid with high levels of sensitivity and specificity.
- Sensitive to delays associated with autism. New, open-ended questions on behavior and expressive language assist in eliciting parent concerns.
- Captures parents' in-depth knowledge. Because ASQ-3 questionnaires are completed by the caregivers who know the child best, they give the most accurate results and save time, and parents become an integral part of the screening process.
- An invaluable parent education tool. With questionnaire items linked to developmental milestones, ASQ-3 helps teach parents about child development and their own child's skills.
- Strengths based. ASQ-3 questionnaires reveal a child's strengths as well as areas of concern, so it's easier to develop a rapport with parents and share results. To schedule a free training session, contact Cathi Durham, GAFP Director of Outreach at (800)392-3841 or cdurham@gafp.org.
Georgia STD Internet Partner Notification Pilot
The epidemiology of sexually transmitted diseases (STDs) is changing as the Internet continues to play a greater role in facilitating sexual encounters. To effectively reach Georgia citizens who have been exposed to STDs, federal, state, and local governments are implementing innovative ways to notify partners through the Internet. In an effort to reach sexual partners, the state STD office is piloting an Internet Partner Notification (IPN) process to notify partners of their exposure to individuals who have been diagnosed with a STD. This process will allow health districts to forward internet contact information to the STD Office for notification via the internet. Partners will be instructed to call the location to obtain additional information about their exposure and the importance of seeking medical attention.
Internet communication has been known to facilitate sexual encounters and is now playing an integral role in understanding the epidemiology of STDs. Because more patients are naming contacts met on the internet, it is imperative that a process be developed to notify these partners of their exposure so that they may be tested and treated. In the United States, health officials reported over 36,000 cases of syphilis in 2006, including 9,756 cases of primary and secondary (P&S) syphilis. In 2006, half of all P&S syphilis cases were reported from 20 counties and 2 cities; and most P&S syphilis cases occurred in persons 20 to 39 years of age. With this in mind, the IPN has been prioritized to reflect the syphilis epidemiologic trends in the state of Georgia. Because the number of infectious syphilis cases has increased approximately 9 percent each year since 2003, there is much optimism that this new process will further intervene in the spread of disease.
For more information, contact Rhonda Burton at rtburton@dhr.state.ga.us, or Cathi Durham at cdurham@gafp.org.
Preconception Care
Georgia in Top 10 for Infant Mortality Rate – What Family Physicians Can Do
Preconception Care – Health Promotion - Series
Continued
Preconception Care Series Continued – Risk Assessment
Preconception Care Series Continued – Intervention
Preconception Care – A Tool for Family Physicians
Preconception Care: The Central Role of Pregnancy
Planning and Contraception by Dr. Anne Lang Dunlop
Georgia in Top 10 for Infant Mortality Rate – What Family Physicians Can Do
Unfortunately, Georgia ranks among the top ten states in the US with the highest infant mortality rate. In Georgia, 70 percent of infant deaths can be attributed to low birth weight of less than 1,500 gm. By improving maternal health, 67 percent of excess feto-infant mortality could be eliminated.
Preconception Care outlines measures that must begin before conception to have maximum impact. These measures include appropriate nutrition and supplementation, as well as screening and treating of substance abuse, STD’s, and chronic conditions. The goal of preconception care is to identify, eliminate or reduce modifiable risks to a woman’s health or her pregnancy outcome, and to identify and educate women about non-modifiable risks. Over the next few months, the GAFP will publish a series of newsletter articles addressing this very real concern of infant mortality and ways a family physician can make a difference.
For more information
or to set up an in-office visit please contact Cathi Durham at 800-392-3841
or at cdurham@gafp.org.
Preconception Care – Health Promotion - Series Continued
Last month we announced that the GAFP Public Health Committee will be providing information regarding Preconception Care through a series of newsletter articles. Primary care physicians can significantly reduce the infant mortality rate in Georgia by providing specific health care measures to women before they become pregnant. There are three main components to preconception care: health promotion, risk assessment, and interventions.
Health promotion consists of health education individualized to a woman’s
or couple’s needs. Some of these considerations include folic acid supplementation;
rubella and varicella vaccination; and screening for syphilis, chlamydia, gonorrhea,
hepatitis B, and HIV.
It is recommended that low-risk women who are capable of becoming pregnant
receive folic acid supplementation of 400 micrograms per day. For those women
at high risk of delivering a baby with neural tube defect (previous infant
or family history, insulin dependent diabetes mellitus, or those taking carbamazepine
or valproic acid), the recommended folic acid supplementation is 4 milligrams
per day. It has been documented that there is a 71 percent risk reduction for
recurrent neural tube defect when the folic acid supplement is 4 milligrams
daily.
Preconception vaccination is an essential element for reducing infant mortality. Women planning to become pregnant should be screened for rubella seronegativity and provided with the vaccination if non-immune. Women who contract rubella during the first trimester have a one-in-four chance of having a baby born with features of congenital rubella syndrome, which includes heart defects, blindness, deafness, and developmental disabilities. Women of uncertain immunity should have a Rubella IgG titre with a booster dose – if not pregnant or planning to get pregnant within three months. Varicella vaccine should also be considered in women who have not had chicken pox. Hepatitis B vaccination should also be considered for women planning a future pregnancy. During pregnancy, the risk of neonatal transmission for acute hepatitis B ranges from 10 percent in the first trimester to 90 percent in the third trimester. Infants exposed to acute infection in utero are at increased risk for low birth weight and preterm delivery.
Infant mortality can further be reduced by screening for sexually transmitted infections (STI’s). Early screening and treatment for chlamydia and gonorrhea prevent adverse outcomes for women and infants. STI’s occurring during pregnancy may result in fetal death, or substantial physical and developmental disabilities including mental retardation and blindness. Untreated syphilis can result in neonatal syphilis, still birth, and other morbidities. Finally, preconception HIV screening of women allows for early counseling and treatment prior to and during pregnancy, reducing viral load and the risk of neonatal HIV transmission.
Health promotion is obviously a vital part of preconception care. Next month we will discuss the risk assessment component. You can learn more about preconception care and earn free CME by viewing Dr. Anne Lang Dunlop’s presentation, “Lowering Infant Mortality in Georgia: Strategies in Family Medicine,” is available at http://www.gafp.org/online_cme.asp.
For additional information contact Cathi Durham, Director of Outreach, (800) 392-3841 or cdurham@gafp.org.
Preconception Care Series Continued – Risk Assessment
GAFP is providing valuable information on Preconception Care through a series of newsletter articles. Primary care physicians can significantly reduce the infant mortality rate in Georgia by providing specific health care measures to women before they become pregnant. There are three main components to preconception care: health promotion, risk assessment, and interventions. This month we are looking at risk assessment.
In addition to educating woman who may become or are planning to become pregnant about vaccinations, vitamins, and screening for infections, family physicians should also concentrate on risk assessment. As recommended by Dr. Anne Lang Dunlop, renowned preconception care expert (and an active GAFP member), there are three main areas to assess – substance screening and treatment, chronic disease control and medication management, and nutritional disorders management.
It is more important than ever to address tobacco and alcohol use during the assessment phase. Tobacco use is the leading preventable cause of low birth weight babies. It is also associated with placental abruption, preterm delivery, placenta previa, and miscarriage. Along with tobacco cessation counseling, women (and men) who are planning a pregnancy should be offered adjunct therapy such as a nicotine patch or gum. Alcohol use is the leading preventable cause of mental retardation. Not only does it affect all stages of pregnancy, there is no threshold of alcohol use that has been identified as safe during pregnancy. Clinical trials have shown that screening and brief behavioral counseling interventions in a primary care setting has reduced alcohol misuse.
Chronic disease control and medication management is essential for all women, and especially so for those planning to become pregnant. Women with pre-existing diabetes can decrease the risk of congenital malformations by achieving euglycmeic control before conception and maintaining near euglycemic control (<1 percent above normal range) during organogenesis. Additionally, women with hypothyroidism should be tested for appropriateness of the level of thyroid hormone replacement. Often the dosage of thyroid replacement needs to be adjusted in early pregnancy for proper neurological development of the fetus. Also women who are planning to become pregnant and are using oral anticoagulants should be counseled that treatment may need to be changed to a non-teratogenic anti-coagulant. Finally, women using medication for seizure disorders may also need to alter their treatment to a less teratogenic treatment prior to conception. Although anticonvulsant medication has a teratogenic risk, seizures increase the risk of malformations in the fetus.
Furthermore, women who are overweight should be counseled about risks including neural tube defects, preterm delivery, diabetes, hypertension, and thromboembolic disease. Screening and intensive counseling with behavioral interventions have been shown in clinical trials to promote sustained weight loss for obese adults.
Risk assessment is as important as health promotion when considering preconception care. There are multiple measures family physicians can take that will result in a decrease of infant mortality in Georgia. As we continue this series on Preconception Care, next month we will discuss specific interventions family physicians can take that will make a real difference.
You can learn more about preconception care and earn free CME by viewing Dr. Anne Lang Dunlop’s presentation, “Lowering Infant Mortality in Georgia: Strategies in Family Medicine,” at http://www.gafp.org/online_cme.asp.
For additional information contact Cathi Durham, Director of Outreach, (800) 392-3841 or cdurham@gafp.org.
Preconception Care Series Continued – Intervention
Primary care physicians can significantly reduce the infant mortality rate in Georgia by providing specific health care measures to women before they become pregnant. There are three main components to preconception care: health promotion, risk assessment, and intervention. You can view last month’s article on risk assessment in the January enewsletter at www.gafp.org; this month we will look at the last component, interventions. Next month we will offer tools for integrating preconception care with primary health care.
Family physicians are uniquely positioned to influence outcomes since the patients they see include females of all ages. “Every woman, every time” adds an anticipatory element essential to preconception care. In addition to speaking with women that are planning a pregnancy, it is also imperative to counsel all women who are capable of becoming pregnant as almost half of pregnancies are unplanned.
Primary intervention covers educating these women regarding the need to plan their pregnancy with a health care provider, focusing on reproductive potential, future pregnancy, and the impact of pregnancy on maternal and infant outcomes. It is particularly important to intervene given the high rate of unintended pregnancies and the low rate of pregnancy planning with a provider: 49 percent of pregnancies are unintended, unwanted or mistimed (Henshaw, S.K. Family Planning Perspectives 1998).
One tried and true intervention method was discussed during the Infant Mortality Summit hosted by the Georgia Division of Public Health. Alfred W. Brann, Jr, MD, Professor of Pediatrics, Emory University School of Medicine reported that there is a change noted in a woman’s reproduction when she is requested to write out her goals for the next year. When asked to do this at the six week check of her infant, nearly every woman includes not getting pregnant as part of her goal. The act of actually writing this down has shown to be very effective in avoiding unintended pregnancies. Additionally, by counseling the woman, and her partner, on birth control methods, the effectiveness of preconception counseling is increased further.
For more information, contact Cathi Durham, GAFP Director of Outreach at cdurham@gafp.org or (800) 392-384.
Preconception Care – A Tool for Family Physicians
Family physicians can significantly reduce the infant mortality rate in Georgia by providing specific health care measures to women before they become pregnant. Over the past three months, the GAFP newsletter has featured articles on the three main components to preconception care: health promotion, risk assessment, and interventions. This month we will review tools available for integrating preconception care with primary health care.
The Georgia Academy of Family Physicians, in collaboration with the Georgia Division of Public Health, is excited to announce the release of a Preconception Toolkit developed by our very own, Dr. Anne Lang Dunlop.
The toolkit includes information on:
- Screening for reproductive intentions and risk of unintended pregnancy
- Assessing for medical, obstetrical, psychosocial, environmental, and genetic/familial risks
- Documenting proper CPT codes for reimbursement of preconception care services
A toolkit was mailed to you in March. For additional information contact Cathi Durham, GAFP Director of Outreach, at (800)392-3841 or by email at cdurham@gafp.org.
Preconception Care: The Central Role of Pregnancy Planning and Contraception
Dr. Anne Lang Dunlop, GAFP member and preconception care expert, submitted the following article as the final piece to wrap up the six month preconception care article series in the GAFP newsletter.
Unintended pregnancies, short interpregnancy intervals, and the presence of specific risk factors and risk behaviors (lack of folic acid supplementation, poor control of chronic conditions, use of alcohol, tobacco, and street drugs) are linked with adverse pregnancy outcomes, including preterm and low birth weight births, which are leading contributors to infant mortality. Conversely, the improvement in women’s preconception health and achievement of planned and well-spaced pregnancies are associated with improved pregnancy outcomes and reduction in infant mortality. In fact, the Institute of Medicine notes that among the best protections against adverse pregnancy outcomes are to support women to have planned, optimally-spaced pregnancies and to enter pregnancy in good health.
Approximately half of pregnancies in the United States are unintended, and anywhere from 18-30 percent of pregnancies (depending upon maternal race/ethnicity) follow a short (< 18 month) interpregnancy interval. Research conducted in metropolitan Atlanta reveals that approximately 25 percent of women of reproductive age seeking primary health care services could be classified as at risk for unintended pregnancy based upon their answers to a screening assessment of their sexual and contraceptive practices. To address this issue, the Select Panel on Preconception Care was convened in 2005 by CDC and consists of nationally recognized experts from a variety of disciplines including those from obstetrics, family medicine, pediatrics, public health, reproductive health, and chronic and infectious disease. This esteemed panel has identified the need for health care professionals to play a direct role in screening women for the risk of unintended pregnancy and sexually transmitted infection and in offering family planning, contraceptive counseling and methods, when appropriate, as part of women’s routine health care. The Select Panel for Preconception Care specifically recommends that routine health promotion activities for all women of reproductive age begin with an assessment of women’s reproductive plans, which includes screening women for their intentions to become or not become pregnant in the short and long term and their risk for conceiving a pregnancy (whether intended or not).
The link between the reduction in unintended pregnancy and the provision of contraceptive services, including education and counseling regarding the appropriate use of particular methods, to women who do not desire pregnancy is obvious. Approximately 52 percent of unintended pregnancies result from couples not using contraception, 43 percent from inconsistent or incorrect use of contraception, and only 5 percent from contraceptive failure.
Less well recognized, albeit similarly important, is the link between the provision of family planning and contraception services as part of the care of women who desire a future pregnancy. Such services are important as they enable women to plan for their families by spacing, timing, and limiting their pregnancies. By promoting healthy spacing between pregnancies, family planning services address an important risk factor for low birth weight and preterm birth and, ultimately, infant mortality. By delaying and timing pregnancy, family planning services are important for reducing adolescent and teen pregnancies and for helping women with chronic medical conditions time their pregnancies to occur when their chronic health condition is under optimal control.
There are several medical conditions, as well as medications for treating those conditions, that are associated with adverse pregnancy outcomes. Importantly, there is evidence that the impact of these medical conditions on pregnancy outcomes can be altered by preconception measures. Thus, avoiding, delaying, or achieving optimal timing of a pregnancy in relation to the medical condition or the utilization of a particular medication regimen is an important component of preconception care. For many of the same medical conditions for which preconception care and pregnancy timing are important, there are considerations and criteria related to the selection of appropriate contraceptive methods (e.g., diabetes, hypertension). It is important to note, however, that while a given contraceptive method may present risks to a woman’s health in the setting of a particular medical condition, the risks presented by a pregnancy or a poorly timed pregnancy may outweigh the risks of the contraceptive method.
Given the high rates of pregnancies that are unintended, poorly spaced, and end in preterm and low birth weight births in Georgia and the recommendations of the Select Panel on Preconception Care, the Georgia Division of Public Health has developed a reproductive plans assessment tool that identifies women who are planning to become pregnant within the next 12 months or at a later point, and those who are at risk of becoming pregnant (regardless of plans) because of lack of or inappropriate use of contraception. The reproductive plans assessment tool is designed to be completed in the health care setting by women of reproductive age at least annually. A similar tool, when utilized in a family planning clinic setting, has been shown to increase subsequent pregnancy planning and intentness.
The reproductive plans assessment tool is actually one component of the Preconception Care Toolkit developed by the Georgia Division of Public Health. Other items contained in the Toolkit include:
- Questionnaires for screening for medical, obstetrical, psychosocial, environmental, and genetic/familial risks to pregnancy outcomes;
- Brochures to aid in educating and counseling patients about preconception health, pregnancy planning and spacing, and particular conditions that present risks to pregnancy outcomes, including steps they can take now to improve their preconception risks.
- A checklist for tracking performance of recommended preconception screenings and interventions;
- A billing sheet of CPT codes for reimbursement of preconception care services.
To obtain a reproductive plans assessment tool for incorporation into your practice, or the complete Preconception Care Toolkit, contact Cathi Durham, GAFP Director of Outreach, at (800)392-3841 or by email at cdurham@gafp.org.
Syphilis: The Hidden Epidemic
Primary and secondary syphilis continues to be a serious health issue in Georgia. In 2007, Georgia ranked 3rd in the nation for primary and secondary syphilis and ranked 16th for congenital syphilis. Our primary and secondary syphilis case rates have steadily increased each year, from 4.6 per 100,000 in 2001 to 7.3 per 100,000 in 2007. During this period, the male to female case rate is notably higher among males. This disparity is due to an increase in cases among men who have sex with men (MSM). Primary and secondary syphilis remains concentrated in Atlanta’s Metropolitan Region that includes Fulton (30.5), DeKalb (19.6), Cobb (8.4), Gwinnett (6.1) and Clayton counties (13.6).
Syphilis, a systemic and sexually transmitted disease, is caused by a spirochete bacterium called T. pallidum. Patients who have syphilis might seek treatment for signs or symptoms of primary (i.e., ulcer or chancre at the infection site) or secondary syphilis (manifestations that include, but are not limited to, skin rash, mucocutaneous lesions, and lymphadenopathy). Latent infections (no signs or symptoms) are detected by serologic testing.
Syphilis during Pregnancy
All women should be screened serologically for syphilis during the first trimester of pregnancy. Communities and populations in which the prevalence of syphilis is high or for patients at high risk, serologic testing should be performed twice during the third trimester, at 28 to 32 weeks’ gestation and at delivery. Infants should not be discharged from the hospital unless the syphilis serologic status of the mother has been determined at least one time during pregnancy and preferably again at delivery. Any woman who delivers a stillborn infant after 20 weeks’ gestation should be tested for syphilis.
CDC recommended treatment for adults
Benzathine Penicillin G 2.4 million units IM is the preferred drug for treatment for all stages of syphilis, except for neurosyphilis where aqueous crystalline penicillin G or procaine penicillin with probenicid is recommended. Please refer to the CDC guidelines for treatment details and recommendations for penicillin allergic patients.
Management of Sex Partners
Persons exposed sexually to a patient who has syphilis in any stage should be evaluated clinically and serologically then treated with a recommended regimen:
- Persons who were exposed within 90 days preceding the diagnosis of primary, secondary, or early latent syphilis in a sex partner might be infected even if sero-negative; therefore, such person should be treated presumptively.
- Persons who were exposed greater than 90 days before diagnosis of primary, secondary, or early latent syphilis in a sex partner should be treated presumptively if serologic test results are not available immediately and the opportunity for follow up is uncertain.
- Long-term sex partners of patients who have latent syphilis should be evaluated clinically and serologically for syphilis on the basis of the evaluation findings.
Syphilis is a mandated notifiable disease. For more information on Georgia’s reporting laws, visit the Georgia Department of Community Health, Division of Public Health at http://health.state.ga.us. For additional information on syphilis diagnosis and treatment, visit the Centers for Disease Control and Prevention website at http://www.cdc.gov/std.